Healthcare Provider Details

I. General information

NPI: 1861916827
Provider Name (Legal Business Name): FARM TO TREATMENT TABLE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 07/21/2022
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5354 W 25TH AVE
EDGEWATER CO
80214-1244
US

IV. Provider business mailing address

5354 W 25TH AVE
EDGEWATER CO
80214-1244
US

V. Phone/Fax

Practice location:
  • Phone: 303-931-6478
  • Fax:
Mailing address:
  • Phone: 303-931-6478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BECKY KELLOGG
Title or Position: OWNER/PRESIDENT
Credential: MS PT
Phone: 303-931-6478